To err is human, managed care backs off, the electronic pediatrician; Eye on Washington


To err is human

According to a study published last month by the Institute of Medicine (IOM), a division of the National Academy of Sciences, medical errors are a major threat to your patients' life and well- being. Estimates of hospital deaths caused each year by medical errors range from 40,000 to 98,000, depending on which of two major studies the IOM cites. Even using the lower estimate, those figures are higher than yearly death rates from highway accidents, breast cancer, or AIDS. In-hospital deaths are most easily tracked, but serious errors occur in other settings as well: outpatient surgical centers, retail pharmacies, nursing homes, and patients' homes. Deaths from medication errors in and out of hospitals, for example, add up to 7,000 a year.

The IOM report, titled To Err Is Human: Building a Safer Health System, starts from the proposition that medical errors result not from individual carelessness but from confusing similarities in drug names and packaging, illegible handwriting on prescriptions and patient records, the uncoordinated information about treatments that patients receive from multiple sources of care, and other "system" flaws. It follows that, if errors are to be reduced, medicine must move on from the traditional concept of error as sin--perhaps to be covered up, perhaps punished--to analyses of why mistakes occur and what systemic changes could be made to prevent them.

To accomplish that, the study panel wants Congress to create a Center for Patient Safety that would serve as a clearinghouse for information on medical safety, set goals for reducing errors, and track progress toward those goals. To make sure that data on errors are available, the report wants mandatory reporting of serious mistakes, initially by hospitals and eventually by all health-care providers. Currently, such reporting is mandated in only 20 states, and no cohesive, nation-wide effort to improve safety in health care is in place.

Regulators and accrediting and licensing agencies should make patient safety a key component of their evaluations, and buyers of health insurance must make safety a prime concern in their contracting decisions. To order a copy of To Err Is Human, call the National Academy Press at 800-624-6242.

Managed care backs off

Nothing upsets consumers and physicians more than the denial of medical treatment by an insurer, especially when the decision appears to be made by a "faceless bureaucrat" rather than a physician. You can hear the outrage in the testimony of witnesses before Congressional committees investigating managed care, and see it in newspaper accounts of patients suing their health plans for refusal to pay for so-called experimental treatments such as bone marrow transplants for breast cancer patients.

Now United Health Group, one of the largest managed care companies in the country, has decided to stop providing this opportunity for managed care bashing. From now on, United says it will stop interfering with decisions doctors make about hospitalization or treatment. According to the company, which says it approves nine out of 10 care decisions anyway, the change in policy will save about $100 million a year, which the company currently spends on screening treatment decisions. For overall cost control, United will continue to depend on gathering statistics, developing practice guidelines, and disciplining physicians whose decisions are consistently outside mainstream parameters.

Other managed care companies declined to comment on United's announcement, but physician and consumer groups hailed the company's decision. According to Thomas Reardon, MD, President of the AMA, the action was "historic ..., a long overdue victory for American patients and the care they receive." Just possibly, it's the wave of the future.

The electronic pediatrician

As health-care Web sites proliferate, pediatricians need to keep up on what's out there on the Net. Some new sites we've heard about recently:

  • www.kidsgrowth.com, a combination site that includes practice management information for pediatricians, educational material for parents, and straight-from-the-shoulder information for teens on everything from emergency contraception to anorexia. Kidsgrowth's advisory board includes Contemporary Pediatrics' consulting editor Roberta K. Beach, MD.

  • www.fda.gov/cder/ pediatric, a section of the Food and Drug Administration's Web site that provides information about pediatric drug studies.

  • www.epilepsyfoundation. org for information on epilepsy for physicians and families, including the new HOPE Mentoring Program. It helps epilepsy patients and medical professionals work together to provide educational support and first-hand understanding of the disorder for patients and family members.

  • www.MDchoice.com, a site that incorporates new search engine technology to help physicians access peer-reviewed medical journals, textbooks, photographs, and radiologic studies.

  • www.KidAllergy.com, a site for parents that addresses some of the physical and emotional issues that accompany allergies in children. The site is copyrighted by Pfizer, the manufacturer of Zyrtec antihistamine tablets and syrup.

  • www.909shot.com, where the National Vaccine Information Center purveys horror stories about adverse reactions to vaccines. The site includes material on "hot lots" of pertussis vaccine associated with adverse reactions, links between immunization and SIDS, autism, and juvenile diabetes, and a press release that questions the standards the FDA relied on for licensing Rotashield.


February 18­20, 2000, First Annual Pediatric Integrative Medicine Conference, Tucson, AZ. For information, call 520-626-6858 or e-mail pedsimo@peds.arizona.edu

March 3­4, Behavioral Pediatrics: Clinical Problems in Primary Care. To register, call 617-638-4605

March 22­26, Society for Adolescent Medicine: Adolescence and Violence, Arlington, VA. To register, call 816-224-8010 or fax 816-224-8009

March 23­29, American Academy of Environmental Medicine, Kansas City, MO. To register, call 316-684-5500 or e-mail aaem@swbell.net

March 24­26, Lyme Disease Foundation, Farmington, CT. To register, call 860-525-2000 or fax 860-525-8428.

--Judith Asch-Goodkin
Contributing editor


Congress is home for the holidays and members are relaxing with their families, mending political fences, and finding out what's on their constituents' minds. To judge from the prominence it gets on the Presidential candidates' agenda, health care is a major preoccupation. Rapidly rising prices for prescription medications in particular and health insurance coverage in general are major concerns for many voters, and members of Congress will undoubtedly spend much of their time probing constituents' suggestions for remedies.

Meanwhile, even when Congress is not in session, the federal government continues to function. Items:

President Clinton gave a boost to IOM recommendations on patient safety (see To Err Is Human, above) by ordering health-care providers under direct federal control to adopt all feasible techniques for reducing medical errors. The order would affect some 85 million Americans whose health care is provided or financed by agencies of the federal government.

The National Highway Traffic Safety Administration has proposed that all car manufacturers install release handles inside the trunks of all cars produced after January 1, 2001.

The Healthy People 2010 initiative, an update on the nation's goals for health in the first decade of the new millennium, will be released by the Department of Health and Human Services on January 25. This is the third set of decade-long health goals the government has published, and it addresses such trends as a more diverse, aging population and emerging new health risks. It calls for a refocusing of health policies and expenditures on the long-term investment for a lifetime of good health and an end to disparities in health status for disadvantaged groups in the population.

The Food and Drug Administration has announced plans to require food manufacturers to include specific information on amounts of trans fatty acids (liquid fats that have been turned into solids, in some margarines and shortening products used in many baked goods) on nutrition labels. Consumers will not see any immediate changes in food labels, however; finalizing and implementing the new rules will take several years.

The Department of Housing and Urban Development is preparing a class-action law suit against gun manufacturers, on behalf of the 3 million tenants who live in HUD­supported housing projects. According to HUD Secretary Andrew Cuomo, the goal of the suit is to induce manufacturers to negotiate with the government on introducing gun safety measures.

The National Labor Relations Board, in a reversal of an earlier stand, has ruled that interns and residents at privately owned hospitals are employees, not students, and therefore have the right to form labor unions.

The Federal Trade Commission's Bureau of Consumer Protection has launched Operation Cure.all, a program aimed at stopping the marketing of unsafe and bogus medical products on the Internet by educating consumers on how to spot fraud. According to the FTC, patients surfing the Net should be wary of catch phrases like "scientific breakthrough," "secret formula," and "ancient ingredient"; quotes from so-called medical experts claiming amazing results; and claims that government or medical professionals have conspired to suppress a product. For up-to-date information on fraudulent health claims, go to the consumer portion of the FTC Web site, www.ftc.gov.

The National Institute of Drug Abuse has begun a "Club Drug" initiative aimed at alerting the public to the dangers of drugs such as Ecstasy, GHB, and Rohypnol that teens and young adults are trying at all-night dance parties or "raves." For more information to share with your patients, call NIDA at 800-729-6686.

. Updates. Contemporary Pediatrics 2000;1:13.

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